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Loss of earning power form

Lep compensation form washington state 2026

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The document is an application form for L.E.P. (Loss of Earnings Protection) Compensation from the Department of Labor and Industries. It outlines the process for workers to apply for compensation due to workplace injuries, requiring sections to be completed by the worker, employer, and attending physician. The form collects information on work hours, earnings, benefits, and medical conditions related to the injury.

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Click ‘Get Form’ to open the lep compensation form in the editor.
Begin by completing the Worker’s Section. Fill in your work position, claim number, and dates of injury and request. Indicate your working hours and gross earnings for the specified period.
Answer questions regarding your employer's contributions to medical benefits and whether you are still receiving these benefits. Ensure you sign and date this section.
Next, move to the Employer’s Section. If your employer is filling it out, they should provide wage details for the specified period, including any vacation, sick leave, or holiday wages paid.
Finally, have your attending physician complete their section regarding your diagnosis and ability to return to work. They will need to indicate any restrictions and anticipated recovery timelines.

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